Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (nonfractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.

INTRODUCTION Charcot neuroarthropathy, also known as Charcot foot, is a complication of diabetes mellitus where there is progressive degeneration of the joints, but it potentially is devastating in its consequences. 1 It commonly affects the middle of the foot, hind-foot joints, the ankle, and forefoot joints, and it is believed to result from inflammation in the foot that becomes abnormally protracted due to the underlying neuropathy. 2-8 The prevalence of Charcot neuroarthropathy is up to 13% in individuals with diabetes. 9-11 Patients with Charcot neuroarthropathy encounter increased morbidity and decreased quality of life and mortality. 2,4,5,12,13 If there is a delay in treatment, Charcot neuroarthropathy could result in ulceration and infection which can lead to amputation of the limb. 12-16 These patients have a significant financial impact on the health care system through primary care, community care, outpatient costs, increased bed occupancy, and prolonged stays in hospital. Charcot neuroarthropathy poses many clinical challenges in its diagnosis and management. The often asymptomatic nature of the condition is very similar to ankle sprain, cellulitis, venous thrombosis, inflammatory arthritis, or gout in a healthy patient. 5,16-22 Missed diagnosis is as high as 79% which ultimately leads to a delay in treatment for an average of 29 weeks. 11,16,17,20,23-25 Charcot neuroarthropathy is caused by multiple factors, but essentially it is the result of peripheral neuropathy which is a complication associated with many diseases. 2,4,5 The underlying peripheral neuropathy can skew the pain perception the patient experiences and can mislead the clinician on their differential diagnosis of an "inflamed foot". A thorough neurological examination of the foot can uncover the underlying inflammatory and osteolytic disease process of Charcot neuroarthropathy. 2,4,11,19,26-29 Early recognition and intervention is imperative to avoid the rapid progression toward permanent foot deformity, ulceration, and the possibility of limb loss. 16,30,31 There are multiple review articles about Charcot neuroarthropathy 2,11-13,16,23,25,28,32-34 , but a lack of guidance on foot screen strategies for primary care and emergency room physicians. There is a need for a comprehensive guideline for initial diagnoses and management on foot care to advocate for increased awareness, thereby leading to earlier diagnosis and treatment by a multidisciplinary team.

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